Wherein a surgeon tells some stories, shares some thoughts, and occasionally shoots off his mouth. Like a surgeon.

Friday, August 21, 2009

Stupid

Uuggggghhhhh.

Sorry.

I feel dirty, I need a shower, I may have to kill myself. Where are the death panels when you need them?

So Jon Stewart interviewed Betsy McCaughey last night, on The Daily Show. She's the one credited with raising alarms about the dastardly implications in the health care bill regarding end of life counseling. "Death panels," evidently, wasn't her exact term. "Disgusting," is what she said she wrote in the margins when reading it.

There was a point to which she kept returning (in between quite amazing dramatic gestures to the audience -- the kind when a stand-up comedian goes, "Am I right? Am I right? Huh? Huh?"). Medicare reimbursement is increasingly tied to performance standards, and it's an issue about which I've writtena bit, and which, in its execution, is potentially problematic for all doctors. Nevertheless, her interpretation regarding end of life counseling was utterly, idiotically, cosmically ass backwards. Can you get it that wrong by mistake? Or must you be a willful liar? The lady, after all, was Lieutenant Governor of New York for a moment, which likely puts her in the upper four-fifths of the population in intelligence.

Doctors, she said, will be reimbursed, in part, based on the percentage of their patients who are given end of life counseling. Okay. And, she said, it will also depend on the percentage of cases in which the wishes were carried out. It's at that point that she went off the rails so grandly that, had I not been paralyzed with disbelief, I'd have reached for the remote. And shoved it up my nose. Aiming for my brain.

Her interpretation -- this former politico and self-styled patient advocate -- is that doctors get dinged if their patients change their minds. Really. That's what she said and, apparently, believes. (Okay, she may not believe it: she is, after all, a Republican hack trying to derail health care reform.) You sign an advance directive, that's it. No changes. Any doctor who allows changes gets penalized by THE GOVERNMENT. The lady is an idiot. And, sadly, Jon Stewart didn't call her on it.

Here's the thing: advance directives are for the time when you can no longer make your own decisions. By definition, that means as long as you have the ability, you can change your mind any time you want. In the hospital. In the ICU. Anywhere, anytime. Advance directives are not in effect until you are no longer able to express your wishes. What the bill is doing is making sure doctors follow the patients' expressed wishes when they're no longer able to express them. If a patient has said they want everything done, the doctors must do so. If they've said they don't want to be put on breathing machines, the doctors must honor that request.

It's about following the patients' request. It's about protecting the wishes of patients. I repeat myself. But the lady blew my mind. She couldn't understand her way out of a paper bag.

So this is where we are. This is the level of debate. In a matter as important as this, it's really appalling and disheartening to watch. It's not as if the issues aren't worth discussing. Tying reimbursement to adherence to certain standards is a tricky issue. But if we're going to have the discussion, let's have it with at least a toe still attached to the fundaments. Same with advance directives.

As long as people like that lady get air time without proper rebuttal (in fact, as long as idiocy that deep gets air time at all), we'll never have the kinds of discussions that we need. And deserve.

19 comments:

I caught you from HuffPost. Thank you for clarifying what I was trying to get into words. I had documents for my mom. When the time came, it was on me to decide what was best. ME, not the Dr's or the gov't. ME, as I had wanted it to be, and as it needed to be.

When you put it that way, what she is really arguing for is the right of some other person to overrule a person's living will and take those end of life decisions AWAY from the dying patient. I saw it with my grandfather who did not have a living will and had 6 kids who had to make decisions on his behalf - a few of whom, because of their own beliefs and personal issues, didn't want to let go even though their dad had made it clear (unfortunately just not in a legal document) that he wouldn't want extensive intervention at the end. What the bill actually says is that doctors will be rewarded for actually carrying out the wishes of their patients rather than getting steamrolled into doing otherwise by family members who may not have the best interests of the patient in mind. Unfortunately, the Right-Wing of this country has been pushing the fear button... and it seems to work.

Perhaps the one possible good that MAY come of all this is that more families will begin the conversation about end of life issues.

I recently had OP surgery and as a part of the intake process I was asked "do you have an Advanced Directive?" You should have seen the look on the Nurse's face when I said yes, here is a copy for my record.

I wish one day you would explain a part of this that I ( I bet many others too) don't quite understand about Advance Directives. It is...

What about if you are very ill, but not terminally ill, and at the same time, you are "temporarily" non-responsive? You also have an advance directive that states "no ventilators, etc"...?

The possibility of this circumstance, is why I hold back on having one of these things in my medical records.

My friends husband was very ill and almost died this last winter and spring. He needed to go on a vent. He did not have an advance directive, so his family decided he will go on a vent. He was on it for about 10 days, or 2 weeks, and came off of it. He recovered, went home and is out mowing grass and working on his old car he is restoring. He feels and looks great now.

What would have happened if he would have had an advance directive stating no vent? I have asked him about it and he is certain he would have made one out if asked by doctors, and he would have stated not to have a vent. but, I can tell you he is certainly glad now that he had one.

I'm glad your husband recovered. These advanced directives should be more thorough that "vent" or "no vent". That is where the counselling advocated by the bill comes in. There are many medical situations that the average person could not anticipate. My own mother had an advanced directive, as well as a medical proxy, my brother, who had the authority to make decisions on her behalf.

The anonymous comment above this one is pretty good: directives are about much more, which is why having thorough counseling is a good idea, and the opposite of a "death panel." Very few -- if any -- people would direct that under no circumstances would they want to be on a ventilator. It's about when there's no hope of recovery, being kept alive artificially. The situation you describe, "very ill but not terminally ill," simply would not apply.

If, for example, someone were to arrive at the hospital after an accident, unconscious, with a directive that said "no vent" (which it wouldn't, as simply stated as that), no one would deprive that person of a chance to survive. Directives -- as you'd imagine -- are much more thoughtful than that.

Not that this is the place for such a discussion (ie, I wrote about the appendix elsewhere on this blog): nevertheless, having seen this an a couple of similar reports, I remain skeptical. They are interesting hypotheses, but offer no proof. Statements (such as the problem with appendicitis is with our immune system) aren't backed up with any supporting data. Probably because it's hard to imagine a study, in humans, that could be set up to confirm it.

I've seen people with (presumably) congenital absence of the appendix. I've seen people with nothing but a little string of fibrous tissue where the appendix ought to be. And I've taken out a thousand or so without any observable consequence. In the above-referenced post, I mention another study, also. It can't be said with certainty that no function will ever be discovered. It might even be that in other animals that have a larger equivalent organ there IS a bacterial replenishing function. But that article did nothing to show it in humans, other than to raise an interesting possibility. If appendiceal function were critical in that way, I'd think the many studies that have been done on appendectomized patients would have shown something more than they have.

I looked up page 432 while she was on the show. I don't understand English in the same way she does.

Meanwhile, while Gov of Texas, GWB signed the Texas Advance Directives Act of 1999 allowing the hospital to take you off of life support if it is "futile" and your family can't pay for continued life support or get another facility to accept you, even if your advanced directive indicates "DO EVERYTHING."

There clearly does need to be better education about advance directives, since there are obvious misunderstandings about what they do.

The notion that we're just waiting to turn off your vent without consideration as to your prognosis for recovery is as insulting as the idea that, if you are an organ donor, we won't save you.

M'Lynn, thank you -- I'd forgotten about that Texas atrocity. I seem to recall that a couple of years ago there was a case there in which a hospital wanted to pull the plug on a child even though there was a small chance of recovery.

Why not just cut to the chase and declare a value on a year of life? If the surgery you're going to have will cost $200,000 and it will extend your life 3 years, that only equals $150,000 of value so you don't get the surgery. That's how the great socialized systems end up doing it - unofficially - so why shouldn't we?

As for the idea that the government counseling would ever, ever lead anyone to a decision that wasn't solely of their own making, that idea is ridiculous. I believe the VA has the perfect form that President Obama has brought back. Here's the series of very reasonable questions in their "Your Life, Your Choices brochure:

a. I can no longer walk but get around in a wheelchair.b. I can no longer get outside—I spend all day at home.c. I can no longer contribute to my family's well being.d. I am in severe pain most of the time.e. I have severe discomfort most of the time (such as nausea, diarrhea, or shortness of breath).f. I rely on a feeding tube to keep me alive.g. I rely on a kidney dialysis machine to keep me alive.h. I rely on a breathing machine to keep me alive.i. I need someone to help take care of me all of time.j. I can no longer control my bladder.k. I can no longer control my bowels.l. I live in a nursing home.m. I can no longer think clearly-I am confused all the time.n. I can no longer recognize family/friendso. I can no longer talk and be understood by others.p. My situation causes severe emotional burden for my family (such as feeling worried or stressed all the time).q. I am a severe financial burden on my family.r. I cannot seem to “shake the blues.”

These questions are followed by the questions below:

“If you checked "worth living, but just barely" for more than one factor, would a combination of these factors make your life "not worth living?" If so, which factors?

If you checked "not worth living," does this mean that you would rather die than be kept alive?

If you checked "can't answer now," what information or people do you need to help you decide?”

At that point I think it's totally reasonable to have a doctor come in and discuss exactly what they'd like to have happen in the event they run into life threatening problems.

I missed this travesty, but caught Jon Stewart's send up of, ugh, it hurts to even type the words, Glenn Beck.

Jon Stewart is a comedy genius. What is best is, he just moved to my area (my best friend's uncle's house, as a matter of fact). I think I may have to become a stalker.

I just found your blog and absolutely love it. I am about to have my third shoulder surgery (replacement this time). As a control lunatic, I am freaking out about it. I love and trust my surgeon, and I'm a nurse, but have little OR experience. Your insight has been comforting actually. Thanks so much for sharing your knowledge and observations.

About Me

I'm a mostly retired general surgeon. With my surgical blog, my intention is to inform, entertain, and possibly educate the reader about surgery, and about the life and loves of a surgeon: this one, anyway. Don't know what I'm thinking, doing a political blog, too.
In an amazing coincidence, I've also written a book, "Cutting Remarks; Insights and Recollections of a Surgeon." It's about my surgical training in San Francisco in the 1970s, aimed at the lay reader with the goal of entertaining with good stories, informing with understandable details of surgical anatomy, procedures, and diseases. Knowing you, I bet you'd enjoy it. In fact, if you like Surgeonsblog, you'll absolutely love the book!

Boring, Unoriginal, but Important Disclaimer:

What I say here is as true as I can make it, based on my experience as a surgeon. Still, in no way is it intended as specific medical advice for any condition. For that, you need to consult your own doctors, who actually know you. I hope you'll find things of interest and amusement here; maybe useful information. But please, please, PLEASE understand: this blog ought not be used in any way to provide the reader with ideas about diagnosis or treatment of any symptoms or disease. Also, as you'd expect, when I describe patients, I've changed many personal details: age, sex, occupation -- enough to make them into no one you might actually know. Thanks, and enjoy the blog.